Harm Reduction

Over the last two decades, South Asia has witnessed a significant increase in HIV prevalence among drug using populations, particularly those injecting drugs. To stem the twin epidemics of HIV and drug injecting, several countries in the region have introduced needle-syringe and oral substitution programmes among injecting drug users (IDUs). Besides reducing HIV transmission, these interventions bring IDUs in contact with drug treatment and recovery to eventually overcome dependence.

The positive outcomes of such ‘harm reduction’ measures have been endorsed by the World Health Organisation (WHO) and the Joint United Nations Programme on HIV i.e UNAIDS. However, these interventions are not exactly within the bounds of narcotics and/or penal laws. South Asian governments can exercise several legal and policy options to initiate and scale up IDU harm reduction to reduce individual risk and promote public health.

These are among the findings of the report, titled “Legal and Policy concerns related to IDU Harm Reduction in SAARC Countries”. Commissioned by the United Nations Office on Drugs and Crime (UNODC), Regional Office for South Asia, to the Lawyers Collective HIV/AIDS Unit, a non-government organisation (NGO) working on Public Health, HIV and Law in India, the report examines the interface between law, policy and IDU harm reduction practices in Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. It also suggests potential measures to harmonise IDU harm reduction with law.

The report relies on primary and secondary sources of information. It combines a review of international and regional drug conventions and country-specific laws, policies and programmes on drug use and HIV with site visits and stakeholder interviewsincluding with health and narcotics law officials, NGOs, lawyers and representatives fromconcerned ministries, U.N and international agencies. Preliminary findings from the report were peer reviewed individually by country experts and jointly at a Regional Tripartite Review Meeting organised by UNODC from 30-31 March 2006 at Colombo, Sri Lanka.

Across South Asia, narcotic laws proscribe inter alia possession, use/consumption and supply of prohibited drugs. Notwithstanding stringent penalties, no country has seen a diminution in drug use. On the contrary, drug consumption is reportedly on the rise; in some countries, legislative and enforcement action have coincided with a shift towards riskier use, particularly injecting pharmaceuticals with the attendant threat of HIV and blood borne infections. The report cites studies that attribute the phenomenon of injecting pharmaceuticals to non-availability of heroin but finds no conclusive links between narcotic law enforcement & drug consumption patterns in South Asia.

According to the report, interventions to reduce risk of HIV transmission among drug injecting populations through provision of sterile needle and syringes, Methadone and/or Buprenorphine oral substitution, treatment for drug dependence, outreach and peer support, drug safety education and condoms have been initiated by NGOs in Bangladesh, India, Nepal and Pakistan. Though critical to prevent HIV among IDUs and their sexual partners, these programmes have not been implemented at scale and found only partial acceptance in national drug policies.

The report documents statutory hurdles to IDU harm reduction in all countries. Provision of sterile syringes to IDUs is open to prosecution under penal and/or narcotics law as abetment of drug consumption. Though punishable, most country laws allow consumption of prohibited drugs strictly for medical reasons. Oral substitution is; however; not considered treatment as in most jurisdictions; treatment requires ‘giving up drugs’. The report finds varying legal controls on Methadone and Buprenorphine that impact affect availability and access. Furthermore, absence of protocols for prescription and supervision has hindered policy on oral Methadone and Buprenorphine therapy. Across South Asia, treatment for drug dependence is offered through complex penal and civil arrangements leaving a vast majority of drug users without medical and/or social assistance. Information on safe injecting and drug use is scant, and, if offered, would be in contravention of law. Though available, condoms are not supplied in prisons in any country on account of anti-sodomy laws.

The report outlines types of legal interventions that national governments may adopt to bring IDU harm reduction in conformity with law. One such way is to read harm reduction within the rubric of medical treatment. Another option is to offer immunity to heath and harm reduction staff under the good faith exception, ordinarily available to the prosecution. Protecting harm reduction interventionists from penal and civil liability by an overriding ‘non obstante’ clause is yet another strategy. The report recognises that the choice to make amendments vests with individual countries given their particular legal regimes and interpretation of laws by judicial bodies.